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. 2022 Aug 8;17(8):e0271167. doi: 10.1371/journal.pone.0271167

Factors influencing exclusive breast feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study

Ejigayehu Tolessa Bultum 1,2,#, Elias Merdassa Roro 1,*,#, Tsedeke Wolde 1,3,‡, Ilili Feyessa Regasa 1,‡
Editor: Kwasi Torpey4
PMCID: PMC9359562  PMID: 35939427

Abstract

Only about 39% of infants in low- and middle-income countries are exclusively breast-fed for the first six months. In particular, human immunodeficiency virus (HIV) positive women report confusion about the best feeding methods. Exclusive Breastfeeding (EBF) practices in HIV positive mothers are sub-optimal in Ethiopia. This study aimed to identify the main factors influencing EBF among HIV positive breast-feeding mothers. A facility based cross-sectional study was carried out from September 2017 to June 30 2018 among HIV positive mothers with infants aged 6–23 months. Thirteen public health facilities (7 health centers and 6 hospitals) that provided anti-retroviral treatment (ART) and Prevention of mother-to-child transmission (PMTCT) services, found in three districts of West, East and Kellem Wollega Zones, were randomly selected. Respondents were recruited by systematic random sampling techniques from these facilities using client registers as a sampling frame. Data were collected using face to face interviews with a pre-tested questionnaire. Data were entered into EPI info Version 3.5.1 and analyzed using SPSS Version 20 for windows. Candidate variables for the final multi-variable model were selected considering P≤ 0.05 at bivariable analysis. Associations were declared at P≤ 0.05 by assuming Confidence Intervals did not cross ‘1’with corresponding 95%. A total of 218 HIV positive mothers were included in this study. Of these, only 122 (56.0%) practiced EBF in the first six months. The proportion of study participants who initiated EBF within the first hour of delivery was 134 (61.8%). Mean age of study participants was 28.6years with SD ± 4. Mothers’ having received advice on EBF [AOR 3, 95% CI (1.2–6.7)], disclosure of HIV status to someone close to them including their husband [AOR 6, 95% CI (1.2–29.6)] and believing HIV can be transmitted during delivery [AOR 5.2, 95% CI (1.1–24.0)] were found to increase the likelihood of EBF practices among the study participants (P-value ≤ 0.05). In this study, only just over half of the mothers practiced EBF for the first six months. Care providers should continue to encourage mothers to practice EBF in the first six months and to disclosure of HIV status to someone close to them including their partner. Efforts should be in place to curb the risk of HIV/AIDS transmission during delivery. Continues advise for mothers to practice EBF in the first 6 months is still needed.

Background

The risk of mother-to-child transmission (MTCT) of Human Immunodeficiency virus (HIV) through breastfeeding is challenging though it is an accepted traditional way of promoting health for infants and children in developing countries [1]. MTCT of HIV remains the most significant route of HIV infection among children [2]. Annually, 700,000 infants acquire HIV infection from their mothers where, 280,000 of which are infected through breastfeeding [3]. In the absence of interventions during pregnancy and delivery, HIV transmission through breastfeeding could be responsible for as high as a third of all childhood HIV infections [4].

Despite this, the World Health Organization (WHO) recommends Exclusive Breast Feeding (EBF) by HIV positive mothers during the postnatal period in low- and middle-income countries. The high cost of Exclusive Replacement Feeding (ERF) and lack of adequate clean water and poor sanitation [5, 6] means ERF is not feasible or safe in low- and middle-income countries. While breast milk can be a source of HIV, the risk to infants, particularly those in low-income settings, of malnutrition, diarrhea, acute respiratory tract infection, and death if they are not breastfed remains higher [7]. Furthermore, EBF for up to six months is a more effective strategy for reducing the risk of HIV transmission 3-4-fold compared to mixed feeding [6]. The new recommendation from the WHO regarding commentary feeding for the first 12 months found to be a better strategy [8] than the earlier versions of the strategy.

In higher income contexts, the avoidance of breast feeding by HIV positive mothers if replacement is available is acceptable, feasible, affordable, sustainable and safe (AFASS) [6].

In line with the WHO recommendations, the Federal Ministry of Health of Ethiopia has adopted and developed a strategy of infant and young child feeding. According to the national strategy, informed choices that suit the circumstances of the mother are emphasized and the advice for mothers should be tailored to their individual needs to balance the risks associated with replacement feeding with the risks of contracting HIV via breast feeding [4].

However, it should be noted that controversy remains over the optimum time to introduce commentary feeding [9], and women living with HIV/AIDS commonly report feeling confused over breast-feeding methods [5]. For example, studies have revealed a high rate of early cessation of breastfeeding because of the fear of transmitting HIV/AIDS to their babies [10–12]. Such practices have been associated with malnutrition, sudden infant death syndrome, other neonatal morbidity and mortality [13–16]. Such early cessation is common in the critical period for infant growth (4–6 months) among HIV/AIDS exposed children [14].

Though breastfeeding of infants born to HIV positive mothers remains a risk of acquiring HIV infection [17], there is evidence that EBF decreases the chances of HIV infection in exposed infants compared to mixed feeding. This is because Exclusive Replacement Feeding (ERF) is not feasible due to the high cost of supplementary feeds and lack of adequate clean water and poor sanitation in developing countries [5].

In Sub-Saharan Africa, the roll-out of both highly active anti-retroviral (ART) and more limited pre-natal ART, as well as improved understanding of risk factors for HIV transmission through breastfeeding have dramatically reduced the number of infants becoming HIV-infected [18]. However, there is a paucity of studies, which show predictors of breastfeeding cessation among HIV positive mothers in Ethiopia. Identifying factors related to exclusive breastfeeding practices among HIV infected women is important for targeting evidence-based intervention, which helps to increased HIV-free survival.

This study focused on EBF practices among HIV positive mothers in a region of Ethiopia where there have been no previous well-established facility-based studies. The study outcomes can be used to help improve services for these women by identifying the main factors which enhance EBF practices among HIV positive mothers.

Methods and materials

The setting, study design, and populations

The study was conducted from September 2017 to June 2018 in selected health facilities found in East, West and Kellem Wollega districts. The three districts have a population of 4,322,357 with a mean of 1,440,786 in each district and a 1:1 gender ratio. In total there were 893,536 women of reproductive age group (15–45 years old) and about 710,163 under five children at the time of the study [19].

Seven health centers and six hospitals providing ART and PMTCT services were randomly selected for the study. Data were collected by 13 ART nurses from the respective health institutions. Three supervisors were recruited to oversee data collection. Across the 3 districts, an estimated 2,365 HIV positive women were on antiretroviral therapy (ART) with a total of 415 mothers with HIV/ exposed infants (HEI).

A cross-sectional study was conducted among 219 HIV positive mothers with children under six months and attending PMTCT and ART clinics in the selected public hospitals and health centers were randomly selected.

Inclusion criteria

Mothers living with HIV/AIDS with a child aged 6 months or less who voluntarily consented to participate in the study were included.

Exclusion criteria

Mothers living with HIV/AIDS with a child aged 6 months or less who did not consent to participate and/or who were seriously ill and unable to provide informed consent were excluded from the study.

Sample size determination

The study was conducted in thirteen randomly selected government owned health institutions (six hospitals and seven health centers) proving ART and PMTCT services for mothers living with HIV/AIDS. These institutions were selected based on the availability of the aforementioned services and adequacy of client flow.

The sample size (n) required for the study was calculated using a single population proportion with assumptions of 95% confidence interval, 5% desired precision, proportion of HIV positive mothers exclusively breast feed their infants 48.2% [15] and considering 10% for compensation for non-response. The total samples calculated for the study was 219. The total sample size was across each of the 13 selected health care institutions using probability proportional to size (PPS) and the numbers of HIV positive mothers required for the study in each PMTCT/ART clinic was determined. For each selected facility, a sampling frame was prepared. Participants were then selected from their respective health facility using a systematic random sampling technique from the sampling frame. Sampling intervals were determined by dividing N/n (415/219), i.e., every second intervals. The first respondent was selected by blindly choosing one out of two pieces of paper numbered 1 & 2. Every second mothers visiting the health facility to collect ARV medication or for other purposes were recruited and interviewed.

Data collection procedures

The interview questionnaire was prepared by reviewing relevant literatures as part of this study. The interview questionnaire contained eight (8) sections, each addressing different issues. The questionnaire was first developed in English and, translated into the local language (Afaan Oromo) then, back translated to English to check for its consistency by language experts who can understand both languages. The tool was pre-tested among breast feeding mothers to check language clarity, administration procedures and consistency in a similar setting to the study site, but outside of the study catchment area. After pre-testing, data were analyzed and carefully examined for any discrepancy between actual meaning and respondents’ answers. After thorough discussion between study investigators, data collectors, and supervisors, some ambiguous words were modified, and misunderstandings were clarified. Data from the pre-test are not included in this manuscript.

The data in this study were collected by 13 ART nurses from the respective health institutions who were working at ART and PMTCT departments. Three supervisors and the principal investigator performed overall controlling activities of the data collections process. Two days intensive training outlining data collection process and tools was provided for data collectors and supervisors.

Defining study variables

The dependent Variable was EBF. EBF is defined as the consumption of only breast milk with no supplementation of any type of food from birth except drops and syrups such as; vitamins, minerals and medicines [20]. For this study we dichotomized EBF into (‘Yes’ and ‘No’). Those mothers who exclusively breast fed their children for the first six months were labeled as ‘Yes.’ Those mothers who started complementary feeding within the first six months were labeled as ‘No.’

Independent Variables assessed were: Socio economic status of mothers and households, educational status of mothers, income of mothers, antenatal care attendance, occupation of mothers, disclosure of HIV status to spouse, age of mothers, parity and mode of delivery, mother’s decision on the choice of infant feeding, infant illnesses, baby hospitalization, birth weight, hospital and health service, nutritional education of the mother, antenatal care, post-natal care, cultural norms on breastfeeding, child feeding practice and feeding system, mixed feeding (defined as breast -feeding with the addition of fluids, solid feeds and non-human milks in the first 6 months of age) [20].

HIV Exposed Infants were defined as an infant or child born to a mother living with HIV until the infant or child is reliably excluded from being HIV infected [21]. HIV positive mothers refers to women belonging to the age group of 15 to 49 years who are on ART, attending the antenatal and post-natal clinics in the selected hospitals and health centers.

Early termination of breast-feeding was defined as the act of interrupting giving breast milk and making the child accustomed to other food before two years of age [21]. Seriously ill was defined as women who are sick, in bed and unable to provide information.

Data processing and management

Data were entered into EPI info Version 3.5.1 and transferred to SPSS Version 20 for windows statistical package for analysis. Results were reported using standard data presentation techniques including frequency tables, measures of central tendencies and variations. Both bi-variable and multivariable logistic regression analysis were used to determine the association of each independent variable with the dependent variable. Candidate variables for the multi-variable model were identified by considering P≤0.05 at bi-variable analysis. A multi-variable logistic regression model was used to control for the effects of confounders on the outcome variable. Associations were declared if P≤0.05 with 95% confidence intervals and Adjusted Odds Ratio (AOR) reported to show the strength of associations.

Ethics approval and consent to participate

This study was approved by the Wollega University, Institute of Health Sciences, Research Ethics Committee. Letters of permission were also obtained from East, West and Kellem wollega zones health offices and the respective health offices and facilities of the three selected districts and kebeles (the smallest administrative division of the government). A consent form was attached to every questionnaire with a brief information sheet explaining the aims of the study, benefits, and risks of the study to the participants, explaining their full right to withdraw at any time and their right to skip any question that they did not want to answer. Written consent was obtained from each participant. Data were collected after each participant signed a consent form. In cases where data were requested from minors, consent was sought from their parents or guardians. Only those who consented participated in the study. Data were collected at each selected health facility (i.e., hospital or health centers) in an area providing maximum privacy. All individual identifiers were removed to maintain anonymity of participants and each questionnaire was assigned a unique study number.

Results and discussions

Results

Socio-demographic characteristics

Of 219 randomly selected mothers with children aged ≤6 months, 218 participated in this study, a response rate of 99.5%. Of these, the majority of participants, 184 (84.4%) were married. The average age was 28.6 years with standard deviation (SD) of 4. A higher proportion, 139 (63.8%), of participants were protestant. Around 99 (44.0%) had completed grade 1–8. The majority, 194 (89.0%) were Oromo. More than half, 129 (59.2%) were housewives. The mean age of the infants was 6 months (SD ±2.8) and 113 (51.8%) were males (Table 1).

Table 1. Socio-demographic characteristics of study participants (n = 218), West, East and Kellem Wollega Districts health institution west Ethiopia, September 2017 to June 30, 2018.
Variables Frequency Percent P-values
Age of mothers (years) 0.976
 15–19 1 0.5
 20–24 32 14.7
 25–29 96 44.0
 30–34 66 30.3
 >35 23 10.6
Age of child in months 0.552
 6–11 185 84.0
 12–18 33 16.0
Sex of child 0.632
 Male 113 51.8
 Female 105 48.2
Marital Status 0.218
 Single 11 5.0
 Married (union) 184 84.4
 Divorced 16 7.3
 Widowed 7 3.2
Educational status 0.979
 Unable to read & write 26 11.9
 Able to read & write 48 22.0
 Grade 1–8 96 44.0
 Grade 9–12 40 18.3
 College & above 8 3.7
Religion 0.429
 Protestant Christian 139 63.8
 Others 79 36.3
Ethnicity 0.045
 Amara 16 7.3
 Oromo 194 89.0
 Others 8 3.6
Maternal occupation 0.492
 Self Employed 44 20.2
 House wife 129 59.2
 Merchant 26 11.9
 Farmer 11 5.0
 Government employee 8 3.7
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Knowledge regarding the benefits of exclusive breast feeding

Questions exploring participants’ knowledge of MTCT, PMTCT and benefits of EBF found 179 (82.0%) of mothers were aware that HIV could be transmitted through breast milk. 62 (28.4%) mothers did not know that breast- feeding protected the infant from diarrhea. 50 (22.9%) mothers were aware that HIV could be transmitted from mother to child during pregnancy, delivery and breast-feeding.

Obstetric history of participants

Table 2 outline the obstetric history of respondents and the type of feeding advice obtained from health workers. More than half, 119 (54.6%), of mothers had attended more than four antenatal visits. The majority, 214 (98.2%), of the mothers delivered at health institutions and the mode of delivery was spontaneous vaginal delivery, 182 (83.5%). The majority 209 (95.9%) had attended postnatal care (PNC) follow up and 169 (77.5%) had received advice on infant feeding (Table 2).

Table 2. Obstetric history of study participants (n = 218) West, East and Kellem Wollega Districts health institutions western Ethiopia, September 2017 to June 30, 2018.
Variables Frequency Percent P-values
No of ANC follow up 0.091
 Two 17 7.8
 Three 71 33.6
 Four and above 119 54.6
 Don’t remember 11 5.0
Place of delivery 0.337
 Home 4 1.8
 Health institution 214 98.2
Type of Delivery 0.023
 Normal 182 83.5
 Caesarian Section 36 16.5
Post-natal follow up 0.262
 Yes 209 95.9
 No 9 4.1
Feeding advices obtained from HW 0.024
 No 49 22.5
 Yes 169 77.5
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Proportions of HIV positive mothers exclusively breast feeding

Of all respondents, only 122 (56.0%) practiced EBF. The proportion of participants who initiated EBF within the first hours of delivery was 134 (61.5%) while a few, 27(12.4%), initialed EBF twenty-four hours after birth (Table 3).

Table 3. Exclusively breast-feeding practice among HIV positive mothers in west, east and kellem Wollega Districts health institutions western Ethiopia, September 2017 to June 30, 2018.
 Variables Frequency Percent P-values
Exclusive Breast Feeding
 Yes 122 56.0
 No 96 44.0
Do you give colostrum to new born infant 0.257
 Yes 168 77.1
 No 50 22.9
When have you started breast feeding your child? 0.128
 Within one hour after birth 134 61.8
 Within two hours after birth 55 25.3
 Within 24 hours after birth 27 12.4
 After one day 2 0.9
Reason for not giving first milk/ colostrum 0.584
 Her breast has no milk 26 52.0
 The mother is sick 23 46.0
 Health worker advised not to give 1 0.5
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Determinants of exclusive breast feeding

After controlling for the effect of confounders, variables found to be statistically associated with EBF practices among HIV positive mothers were; exposure to feeding advice, disclosure of HIV status to close friends including husbands and mothers who were aware that HIV could be transmitted through delivery (p-value<0.05) (Table 4).

Table 4. Determinants of Exclusive Breast-feeding Adherence among HIV Positive Mothers in West, East and Kellem Health institutions, western Ethiopia, September 2017 to June 30, 2018.
Variables Exclusive breast-feeding status COR (95% CI) AOR (95% CI)
Age of mothers No (n = 96) Yes (n = 122)
 15–19 1(0.8%) 1(0.8%) 0.9(0.7–1.6) 0.4(0.2–9.5)
 20–24 21(21.9%) 11(9.0%) 0.3(0.1–0.9) 0.3(0.1–9.9)
 25–29 39(40.6%) 57(46.7%) 0.8(0.3–2.0) 0.5(0.1–17.9)
 30–34 28(29.2%) 38(31.1%) 0.7(0.3–1.9) 0.3(0.1–3.5)
 35≥ 8(8.3%) 15(12.3%) 1 1
Child feeding advice obtained from HWs
 No 33(34.4%) 15(12.3%) 1 1
 Yes 63(65.6%) 107(87.7%) 3.7(1.9–7.4) 3(1.20–6.7) *
Infant Birth Weight
 ≥2.5kg 3(5.5%) 4(4.4%) 1 1
 <2.5kg 52(94.5%) 87(95.6%) 1.9(1.1–3.3) 1.4(0.7–2.6)
HIV disclosure status
 No 5(5.2%) 6(4.9%) 1 1
 Yes 91(94.8%) 116(95.1) 0.1(0.3–0.6) 6 (1.2–29.6) *
When HIV transmitted
 During delivery 5(5.2%) 17(13.9%) 3.2(1.9–11.0) 5.2(1.1–24.4) *
 During pregnancy 13(13.5%) 14(11.5%) 0.8(0.4–1.8) 0.8(0.3–1.8)
 During Breast feeding 62(64.6%) 50(41.0%) 2.4(0.9–6.3) 2.3(0.8–6.8)
 I don’t know 2(2.1%) 5(4.1%) 1 1
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*Associated at P≤ 0.05

Mothers’ who received advice on EBF were three times more likely to practice EBF than those who were not given advice [AOR 3 (95% CI (1.2–6.7)]. Those who disclose their HIV status to their spouse were six times more likely to adhere to EBF [AOR 6, 95% CI (1.2–29.6)]. Those who were aware that HIV could be transmitted during delivery were more than five times more likely to adhere to EBF than who were unaware [AOR 5.2, 95% CI (1.1–24)] (Table 4).

Discussion

In this study, we assessed factors influencing EBF among HIV positive mothers.

The proportion of mothers with children less than six months who exclusively breast fed their children in this study (56%) was lower than a similar study conducted in Addis Ababa [22]. This may be explained by the different geographical contexts. In Addis Ababa, mothers may be exposed to better media coverage promoting EBF and may have better access to counseling, MTCT and PMTCT services than in our current study setting. Compared to our findings, another study conducted in Tigray region reported a substantially higher prevalence of EBF of 90% [23]. The difference may be explained by methodological variations between studies, socio-cultural factors and health service utilization characteristics among participants in the different study areas.

This study identified important factors related to EBF. Mothers who received advice on child EBF were three times more likely to exclusively breast feed their children than those who were not. A systematic review from low- and middle-income countries concluded that improving the counselling skills of health workers to address breastfeeding problems is a critical component of infant and young child feeding programmes, and would aid in attaining the 2025 World Health Assembly EBF targets [24]. Another systematic review and meta-analysis from Ethiopia reported similar findings [25]. According to the Federal Ministry of Health in Ethiopia, all HIV-infected mothers should receive counseling which includes provision of general information about the risks and benefits of various infant feeding options [26].

Mothers who disclose their HIV status to someone close to them, including their husband, were 6 times more likely to adhere to EBF for the first six months than their counter parts. This finding is consistent with a systematic review and meta-analysis from Ethiopia [25], a study from south Ethiopia [27] and the findings of a similar study conducted in Gondar which showed disclosure of HIV status was independently associated with EBF [11]. The high disclosure rate among HIV positive mothers appears to be strongly associated with the practice of EBF in these mothers [28]. Those who were aware that HIV could be transmitted during delivery were 5.2 times more likely to adhere to EBF than those who did not know the mechanisms of HIV transmission from mother to child.

Our study had some limitations. Our findings need to interpreted with caution as other confounding factors may have impacted when establishing associations as we considered only those variables with P-values <0.05 at bi-variable analysis. We also had limited variables included in the final model.

Conclusion

This study determined that only slightly more than half of the mothers living with HIV/AIDS who had children aged six months or less practiced EBF in the study area. The major factors identified favoring EBF were; being advised by a health extension worker about appropriate child feeding practices, disclosure of HIV status to someone close to them (including their husband) and knowing that HIV can be transmitted during delivery.

Recommendations

Since EBF is a less costly and more practical option in the context of resource constrained countries; health workers should give advice on MTCT, PMTCT and infant feeding practice during PNC follow up to improve the knowledge of mothers in this area. Furthermore, supporting mothers to disclose HIV status to someone close to them (including their husband) by encouraging them to bring them to the health facility and be party to discussions with health care workers may be beneficial.

Limitation of the study

Since the study design was cross sectional, it only explored the association of breast-feeding practices with other explanatory factors. There might be recall biases amongst participants who were reporting retrospectively.

Supporting information

S1 Data

(SAV)

Click here for additional data file. (9.6KB, sav)

Acknowledgments

We thank all participants, data collectors, and field workers for their genuine co-operation. We are also delighted to acknowledge East, West, and Kellem wollega district health offices for their unreserved assistance from the start until the completion of this study. We appreciate Clare Phillips and Christine Andrews for their contributions in language and readability edition of the manuscript. “Tsedeke Wolde passed away before the submission of the final version of this manuscript. Elias Merdassa Roro [Corresponding author] accepts responsibility for the integrity and validity of the data collected and analyzed.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Kwasi Torpey

3 Sep 2021

PONE-D-21-08205

Status of Exclusive Breast Feeding among children born to Human immunodeficiency virus (HIV) positive mothers attending public health facilities in western Ethiopia. Cross-sectional study.

PLOS ONE

Dear Mr Elias Roro,

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"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: General comments

• This is a good topic and will be of great interest to readers

• The manuscript needs to be edited for grammar and syntax (by a native English speaker)

Major comments

Topic: Status of Exclusive Breast Feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia. Cross-sectional study.

• This study is more of Exploring factors associated with or influencing EBF among children born to HIV positive mothers and not status of EBF as stated by the authors

Abstract

• Page 2: The abstract of this paper should contain a statement on the background of EBF among HEIs in Ethiopia. This is missing.

• The purpose the of the study is not consistently stated throughout the paper. The authors claim to be assessing the levels and factors influencing EBF among HEIs while the topic reads Status of EBF. The study should have one clear focus and purpose that’s carried out throughout.

• The proportion of respondents who initiated Exclusive Breast Feeding within the first hours of delivery were 134 out of 218, this should be 61.47% and not 61.8% as reported. (Also choose to use either one or two decimal places throughout the paper).

• There was no mention of husbands but close friends in the results section, authors’ conclusion however reads “disclose their test results to their husbands”. Conclusion should reflect the results.

Background

• Authors need to have a brief but detailed synopsis including statistics of what is known about factors influencing EBF among HEIs particularly in the LMICs including sub-Saharan Africa, what’s not known and the gaps to be addressed by the study. This study’s background lacks such information.

Materials and Methods

• Page 5: Authors claimed to have used a mixed method approach and that qualitative data were used to triangulate the quantitative findings; while this could be true, this paper doesn’t reflect such.

Results

• Page 8-9: The average age is 28.68 in the abstract and 28.6 is the main results section, also SD is reported as ± 4.2 in the abstract and 4 in the results. Authors should check for consistency.

• Page 9: Can the authors include p-values and Odds Ratio in Table 1

• Page 10: Authors claimed that findings from the FGDs supported the ‘knowledge factor’. Their analysis didn’t include any qualitative analysis, additionally, qualitative data doesn’t feature anywhere in the results section.

• Page 10: By stating that majority of HIV positive mothers are not willing to practice EBF because of fear of transmission of HIV through breast milk, but some of them who got advice of health professionals adhere to EBF; this being a key finding, authors should support the same with statistical data (OR, AOR, CI)

• Page 10-11: Table 2 &3: should include inferential statistics as well

• Page 12: Authors have mentioned that they controlled for effect of confounders; they should give a brief description of the statistical model(regression) used to eliminate the confounders [stratification or multivariate methods] at the methods section. Also describe which covariates were controlled, as shown in the descriptive analysis tables 1,2&3

• Page 12: Table 4 - Include p-values in the table or * to follow the OR values; then have a key below the table with asterisks like *p<0.05. **p<0.01. ***p<0.001

Discussion

• Page 13: Mothers who disclosed their HIV status to their close friends were 3 times more likely to adhere to EBF for the first six months than their counter parts. Please check for consistency, is it 3 or 6 times?

• Page 14: The quote by the 29-year-old mother should be in the results. The study mentions qualitative methods using FGD but the findings are entirely quantitative with a tacit mention of the qualitative findings in the results' section. The author should analyze and report the qualitative data to support the triangulation mentioned in the methods. Or if the qualitative results have been published elsewhere, this should be indicated

• Page 14: On strength of the study; authors stated that their findings were triangulated by qualitative data; This is not true. The author did not include a single qualitative quote in the results. Secondly, there is no mention of how the qualitative data was analyzed from coding to theme development.

Minor comments

• Participants were HIV positive mothers; were participants given the option not to participate without any fear of discrimination? like service denial at the health facilities.

• Conclusion should also include contributions to existing literature, significance of results and conclude with your thoughts.

Reviewer #2: Dear Editor

Review of Manuscript PONE-D-21-08205

Thank you for the opportunity to review this interesting manuscript. I am of the view that this manuscript is important given that the authors address an important aspect of breastfeeding for a vulnerable population. Following review of the manuscript, please find my comments as follows.

Comments to the authors

The methods used are technically sound with a fair presentation of quantitative data. The statistical analyses used is adequate for the objectives of the study. However, the quantitative data presented has errors that need to be addressed. The qualitative data presented is also sparse and the paper would benefit from some more qualitative data content. Importantly, the manuscript needs extensive grammatical reconstruction and I recommend that it would benefit from proofreading and copyediting by a high-proficiency English speaker.

The following are detailed comments and recommendations

Title

I recommend the title undergo a grammatical edit. May I suggest the full stop be replaced with a colon i.e. “…western Ethiopia: a cross-sectional study.”

Abstract

The abstract, like the rest of the paper would benefit from extensive proofreading and copyediting preferably by a highly proficient English speaker.

Background

Page 3, paragraph 2: The linkages between the cost of replacement feeding, poor water and sanitation access and EBF recommendations needs to be more explicitly explained in the background section.

Page 4, paragraph 2 & 3: These paragraphs are missing some citations. The entire paragraph, despite citing several findings only cites one publication.

Methods

The methods section is sufficiently detailed with explicit sampling and data collection details. The methods are technically sound and suitable for the objectives of the study.

Results

I recommend that the authors maintain a consistent number of decimal places in the tables presented.

The authors must review the tabular data presented as some of the frequencies and percentages do not add up or tally. Eg Table 2 “No of ANC follow up” and Table 3 “When starts breast feed”

The results section has very little qualitative data representation. I recommend that the results section would be made more interesting with the inclusion of additional quotes from qualitative responses. I recommend that quotes regarding reasons for time of giving colostrum and how HIV status disclosure affected breastfeeding would be interesting and give support to the quantitative results. This would also strengthen the claim of triangulation cited in the strengths section of the manuscript.

I hope that the authors will consider these suggestions in improving the manuscript to address this very important topic. I wish them all the best in this endeavour.

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Reviewer #1: Yes: Jefferson Mwaisaka

Reviewer #2: No

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PLoS One. 2022 Aug 8;17(8):e0271167. doi: 10.1371/journal.pone.0271167.r002

Author response to Decision Letter 0

14 Dec 2021

Response to Reviewers

Title: Factors influencing Exclusive Breast Feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.

Authors: Ejigayehu Tolessa Bultum (ebultum@yahoo.com

Elias Merdassa Roro (emerdassa@gmail.com)

Tsedeke Wolde (tsedekewolde@yahoo.com)

Ilili Feyissa Regassa (liasfeyisa2@gmail.com)

Version: 2 Date: 05 November 2021

Author’s Response to Reviewers Comments: See over

Editor’s Comments

Version: 2

Date: 05 November 2021

Title: Factors influencing Exclusive Breast Feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.

Editor’s comment -1

1. Please ensure that your manuscript meets PLOS ONE’s style requirements, including those for file naming.

Authors Response -1

1. Thank you for the comment. We have now the modified the revised manuscript following PLOS ONE’s style requirements, including those for file naming.

Editor’s comment -2

1. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Authors Response -2

1. We have included additional information in the revised manuscript sufficient details regarding the questionnaire that others could replicate the procedures for development and analysis. But we want to clear out that, this questionnaire is not standardized and, not been validated by other scholars or organizations/institution. Hence, we can share the English version of the questionnaire with you or any other researchers who want to check when asked through our email address on the manuscript. But it may not be appropriate to share it publicly, which may mislead other researchers as this questionnaire might have limitations. This may lead other to repeat same errors as we might have done, especially early career researchers and students. In the revised manuscript, we have provided additional detail information regarding all the procedures, contents of the questionnaire in ‘Data Collection Procedures’ section of the main text of the revised manuscript (line 19-30 on page 6, and line 1-4 on page 7), now read as follows;

Data Collection Procedures

‘The interview questionnaire was prepared by reviewing relevant literature as part of this study design. The interview questionnaire contained eight (8) sections, each addressing different issues. The questionnaire was first developed in English and, translated into the local language (Afaan Oromo) then, back translated to English to check for its consistency by language experts who can understand both languages. The tool was pre-tested among breast feeding mothers to check language clarity, administration procedures and consistency in a similar setting to the study site, but outside of the study catchment area. After pre-testing, data were analyzed and carefully examined for any discrepancy between actual meaning and respondents’ answers. After thorough discussion between investigators, data collectors, and supervisors, some ambiguous words were modified and misunderstandings were clarified. Data from the pre-test are not included in this manuscript.

The data in this study were collected by 13 ART nurses from the respective health institutions who were working at ART and PMTCT department. Three supervisors and principal investigator performs overall controlling activities of data collections process. Two days intensive training was provided for data collectors and supervisor outlining data collection process and tools.’

Editor’s comment -3

1. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

Authors Response -3

1. Thank you for your insightful comment. As you have commented, we have now inserted a statement highlighting the consent obtaining procedures where minors might be involved. It is now appearing the main text of the revised manuscript under ‘Ethics approval and consent to participate’ Section (line 8-20, on page 8), now reads,

‘Ethics approval and consent to participate

This study was approved by the Wollega University, Institute of Health Sciences, Research Ethics Committee. Letters of permission were also obtained from East, West and Kellem wollega zones health offices and the respective health offices and facilities of the three selected districts and kebeles. A consent form was attached to every questionnaire with brief information sheet explaining the main aims of the study, benefits, and risks of the study to the participants, explaining their full right to withdraw at any time and their right to skip any question that they did not want to answer. Written consent was obtained from each participant. Data were collected after each participant signed a consent form. In cases where data were required from minors, consent was sought from their parents or guardians. Only those who consented participated in the study. Data were collected at each selected health facility (i.e., hospital or health centers) in an area providing maximum privacy. All individual identifiers were removed to maintain anonymity of participants and each questionnaire was assigned a unique number.’

Editor’s comment 4

1. Please ensure you have thoroughly discussed any additional potential limitations of this study within the discussion section, including the potential impact of confounding factors.

Authors Response -4

1. In the revised manuscript we have inserted short paragraph on potential impacts confounders in the entry paragraph of discussion section (line 1-4, on page 14). Now it appears as follows;

‘Our study had some limitations. Our findings need to interpreted with causation as other confounding factors may have impacted when establishing associations as we considered only those variables with P-values <0.05 at bi-variable analysis. We also had limited variables included in the final model.’

Editor’s comment - 5

1. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data- availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

Authors Response -5

Thank you for the comment. In the revised manuscript, we have now provided detail information regarding data availability under ‘Availability of data and materials’ section (line 1-6 on page 15). It reads as follow;

‘All data used for the write up of this manuscript are fully available in SPSS readable formats. Results are fully presented in tables, narrations and figures in this manuscript, nothing is left unpresented. The sampling frame with the lists of every respondent is also available in Excel readable format. Data has not been uploaded to a public repository for confidential and ethical reasons.’

Editor’s comment 6

1. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Authors Response -6

1. We have removed ethics statement elsewhere than methods section of the revised main text manuscript. Not it only appears under ‘Ethics approval and consent to participate’ (line 8-20 on page 8).

Editor’s comment- 7

1. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Upon resubmission, please provide the following:

The name of the colleague or the details of the professional service that edited your manuscript

A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file).

Authors Response -7

1. The revised manuscript has been copy edited for language usage, spelling and grammar by health professional from England by a native English speaker. The editor had a rich experience in editing manuscripts. The editor detail information is included in the acknowledgments section of the revised manuscript.

2. We have uploaded the copy-edited manuscript with track change as *supporting inflation* file

Review Comments to the Author

Title: Factors influencing Exclusive Breast Feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.

Reviewer #1: General comments

• This is a good topic and will be of great interest to reader

• The manuscript needs to be edited for grammar and syntax (by a native English speaker)

General comments: Authors Response #1

• Thank for your appreciations and professional interest of the article.

• The revised manuscript is now edited for grammar and syntax by native English speaker and health professional.

Major comments-Review #1

• Topic: Status of Exclusive Breast Feeding among children born to HIV positive mothers

attending public health facilities in western Ethiopia. Cross-sectional study.

• This study is more of Exploring factors associated with or influencing EBF among

• children born to HIV positive mothers and not status of EBF as stated by the authors

Major comments: Authors Response to Reviewer #1

• Topic: Your comment and suggestion are well accepted. We have now modified the title in line with your suggestion. But still, we are open to take any further suggestion for modification. For now, in the revised manuscript, the modified topic reads as follows;

‘Factors influencing Exclusive Breast Feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.’

Abstract: Review #1 Comments

• Page 2: The abstract of this paper should contain a statement on the background of EBF among HEIs in Ethiopia. This is missing.

• The purpose the of the study is not consistently stated throughout the paper. The authors claim to be assessing the levels and factors influencing EBF among HEIs while the topic reads Status of EBF. The study should have one clear focus and purpose that’s carried out throughout.

• The proportion of respondents who initiated Exclusive Breast Feeding within the first hours of delivery were 134 out of 218, this should be 61.47% and not 61.8% as reported. (Also choose to use either one or two decimal places throughout the paper).

• There was no mention of husbands but close friends in the results section, authors’ conclusion however reads “disclose their test results to their husbands”. Conclusion should reflect the results.

Abstract :Authors Response to Reviewer #1

• Page 2: The abstract of this paper now contains a statement on the background of EBF among HEIs in Ethiopian context. In the revised manuscript, now we have inserted background statement integrated with objective of the study (line 2-6, on page 2), which reads as follows,

‘Only about 39% of infants in the developing countries are exclusively breast-fed for the first six months. Human immunodeficiency virus (HIV) positive women were confused about feeding methods. Exclusive Breastfeeding (EBF) practice of Human immunodeficiency virus (HIV) positive mothers is sub-optimal in Ethiopia. Hence, we want to identify the main factors influencing exclusive breast-feeding among HIV positive breast-feeding mothers.’

• Thank you for the comment. We have come to consensus that as you have commented above regarding the title of the article, this comment is also related with the comment above. We have modified title and we have tried to keep the consistency of the article with specific focus with factors influencing EBF among HIV positive mothers with infants less than six months old. Otherwise, we are happy to hear from you with further details, if we could not get the main idea of your comment.

• Great insight, very important comment. It was really an error. Now we have corrected it to 134(61.5%) rounded to the closed decimal point and highlighted in the revised main text manuscript. We have tried to stick to a ‘uniform decimal points’ (we have chosen single decimal point) throughout the paper including data in tables. Now it appears in the main text of revised manuscript (line 3, on page 11).

• Thank you for this critical comment. It was a mistake as well. The mistake emerged from the questionaries (i.e., in the questionnaire we administered to the participants had five choices). Later in the multivariable table 4, we have recoded those five choices into dichotomous variables i.e., ‘YES/NO’. We forgot to change it in the submitted version of the manuscript. Now in the revised manuscript, we have modified/corrected across all sections of the manuscript (i.e.; results, discussion and conclusion) into same/uniform expression. Now it reads;

‘disclosure of HIV status to someone close to them including their husband’

Background: Review #1 Comments

• Authors need to have a brief but detailed synopsis including statistics of what is known about factors influencing EBF among HEIs particularly in the LMICs including sub-saharan Africa, what’s not known and the gaps to be addressed by the study. This study’s background lacks such information.

Background: Authors Response to Reviewer #1

• We had some before. We have added more literatures. We are not sure if it is sufficient.

Materials and Methods: Review #1 Comments

• Page 5: Authors claimed to have used a mixed method approach and that qualitative data were used to triangulate the quantitative findings; while this could be true, this paper doesn’t reflect such.

Materials and Methods: Authors Response to Reviewer #1.

• Dear reviewers, we thank you for your very valuable comment regarding qualitative part of our manuscript. Both reviewers have commented on this issue. We are convinced that, qualitative part of this manuscript is very shallow. We came to consensus that qualitative data to be removed from this manuscript but we have data on hand. We will try to re-analyze and submit it independently for another time. For now, we have removed all qualitative data from this manuscript.

Results: Review #1 Comments

• Page 8-9: The average age is 28.68 in the abstract and 28.6 is the main results section, also SD is reported as ± 4.2 in the abstract and 4 in the results. Authors should check for consistency.

• Page 9: Can the authors include p-values and Odds Ratio in Table 1

• Page 10: Authors claimed that findings from the FGDs supported the ‘knowledge factor’.

• Their analysis didn’t include any qualitative analysis, additionally, qualitative data doesn’t feature anywhere in the results section.

• Page 10: By stating that majority of HIV positive mothers are not willing to practice EBF because of fear of transmission of HIV through breast milk, but some of them who got advice of health professionals adhere to EBF; this being a key finding, authors should support the same with statistical data (OR, AOR, CI)

• Page 10-11: Table 2 &3: should include inferential statistics as well.

• Page 12: Authors have mentioned that they controlled for effect of confounders; they should give a brief description of the statistical model(regression) used to eliminate the confounders [stratification or multivariate methods] at the methods section. Also describe which covariates were controlled, as shown in the descriptive analysis tables 1,2&3

• Page 12: Table 4 - Include p-values in the table or * to follow the OR values; then have a key below the table with asterisks like *p<0.05. **p<0.01. ***p<0.001.

Results: Authors Response to Reviewer #1.

• Good comment. We appreciate for that. Page 8-9: In the revised manuscript the average age is now corrected to 28.6 in the abstract and 28.6 is the main results section, also SD is corrected as ± 4 in the abstract and 4 in the results respectively. We Authors have now checked for consistency. Now it is consistent.

• Page 9: Now we have inserted p-values across tables (1,2 ,3). We appreciate the concerns across the tables regarding P-values and Odds Rations. Tables 1,2, & 3 are just descriptive tables and intends to present frequency of variables only (i.e., descriptive statics tables). Though we were not interested to see a sort of statistical associations (i.e., inferential statistics), here have presented P-values for the sake of your comment, but not Odds Rations here. We also did not find in PLOSONE guidelines and publications as well. We have presented statistical associations (inferential statistics) in table 4.

• Page 10: We will re-analyze it and make separate article rather than using for triangulation for another submission. Hope you will help us more by then.

• Page 10: Thank you for your comment. This statement was taken from Qualitative finding (FGD) summary finding for triangulation purpose. As far as we know, we cannot stablish statistical associations (OR<AOR, CI) from qualitative data. Now the qualitative data were removed from the revised manuscript for the reason we have stated above.

• Page 10-11: Although we have no interest in inferential statistics in tables 1,2,3. We have presented present p-values in tables 1, 2 & 3. We have summarized ‘COR, AOR and CI’ in table 4.

• Page 12: We have briefed already the method we used for controlling for cofounders’ methods section of the main text of the manuscript. Basically, we run ‘multi-variable logistic regression model which was used to control for the effects of cofounders on the outcome variable.’ This phrase comes from the main text manuscript.

• Page 12: In table 4, we have presented AOR with 95% CI. We have followed your suggestion to use ‘*’ to follow the OR values; then have a key below the table with asterisks like *p<0.05. **p<0.01. ***p<0.001.

Discussions: Review #1 Comments

• Page 13: Mothers who disclosed their HIV status to their close friends were 3 times more likely to adhere to EBF for the first six months than their counter parts. Please check for consistency, is it 3 or 6 times?

• Page 14: The quote by the 29-year-old mother should be in the results. The study mentions qualitative methods using FGD but the findings are entirely quantitative with a tacit mention of the qualitative findings in the results' section. The author should analyze and report the qualitative data to support the triangulation mentioned in the methods. Or if the qualitative results have been published elsewhere, this should be indicated

• Page 14: On strength of the study; authors stated that their findings were triangulated by qualitative data; This is not true. The author did not include a single qualitative quote in the results. Secondly, there is no mention of how the qualitative data was analyzed from coding to theme development.

Discussions: Authors Response to Reviewer #1

• Page13: Thank your insightful comment. On page 13, it was an error. Now we have corrected to 6 times, not 3 times. Now it consistent across the revised manuscript.

• Page 14: Thank you for the comment again. Now we have agreed to remove the qualitative issue from this revised manuscript. We may come back with an independent manuscript with qualitative data only.

• Page 14: We appreciate your concerns. We have removed qualitative issues across the entire manuscript. In the revised manuscript, we have modified the strength section.

Minor comments: Review #1 Comments

• Participants were HIV positive mothers; were participants given the option not to participate without any fear of discrimination? like service denial at the health facilities.

• Conclusion should also include contributions to existing literature, significance of results and conclude with your thoughts.

Minor comments: Authors Response to Reviewer #1

• Yes, definitely, in the ethics sections, we have described in detail regarding participants full right to with draw at any time from participation. We presented here again the ethics statements as follows.

‘‘Ethics approval and consent to participate

This study was approved by the Wollega University, Institute of Health Sciences, Research Ethics Committee. Letter of permission was also obtained from East, West and kellem wollega zones Health Offices and respective health offices and facilities of the three selected districts and kebeles. Consent form was attached to every questionnaire with a brief information regarding the main aim of the study, benefits, and risks of the study to the participants, explaining their full right to withdraw at any time, skip any question that they don’t want to answer. Written consents were obtained from each respondent. Data were collected after each respondent signed a consent form based on their full consent. In a case data were required from minors, consents were sought from their parents or guardians. Only those who consented participated in the study. Data were collected at each selected health facility (i.e., Hospital or Health centers) level in an area which gives them the maximum privacy, after getting services. We removed an individual identifier to maintain the anonymity of the respondents by assigning each questionnaire a unique number.’

• Thank you for the comment. In the revised manuscript, we have now modified the conclusion section.

Review comments forwarded from reviewer #2 and authors response to the reviews.

Title: Factors influencing Exclusive Breast Feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.

Reviewer #2: Comments to the authors

• The manuscript needs extensive grammatical reconstruction and I recommend that it would benefit from proofreading and copyediting by a high-proficiency English speaker.

• Title

I recommend the title undergo a grammatical edit. May I suggest the full stop be replaced with a colon i.e. “...western Ethiopia: a cross-sectional study.”

Authors Response to Reviewer #2

• Thank for the comment. The revised manuscript is now copy edited for grammatical errors by health professional native English speaker from England.

• Title grammatical edit. We accept the comment. We have now incorporated your suggestion regarding the replacement of full stop with colon. The title is also modified based on the suggestion from the other reviewer as follows.

‘Title: Factors influencing Exclusive Breast Feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.’

Abstract: Reviewer #2 Comments to the authors

• Abstract

The abstract, like the rest of the paper would benefit from extensive proofreading and copyediting preferably by a highly proficient English speaker.

Abstract: Authors Response to Reviewer #2

• Abstract: The revised manuscript including abstract section is also now benefited from the overhaul copy edited for grammatical errors by health professional native English speaker from England. The profile of the editor is found in the acknowledgments section of the revised manuscript.

Background: Reviewer #2 Comments to the authors

• Page 3, paragraph 2: The linkages between the cost of replacement feeding, poor water and sanitation access and EBF recommendations needs to be more explicitly explained in the background section.

• Page 4, paragraph 2 & 3: These paragraphs are missing some citations. The entire paragraph, despite citing several findings only cites one publication.

Background: Authors Response to Reviewer #2

• In the revised manuscript, we have now explained on Page 3, paragraph 2: the linkages between the cost of replacement feeding, poor water and sanitation access and EBF recommendations in the background section.

• In the revised manuscript we have included the missing citations and rearranged the context the paragraphs during proof reading and copy edition. We have checked for the missing citations and other contexts on Page 3 & 4, paragraph 2 & 3.

Methods: Reviewer #2 Comments to the authors

• The methods section is sufficiently detailed with explicit sampling and data collection details. The methods are technically sound and suitable for the objectives of the study.

Methods: Authors Response to Reviewer #2

• Thank you very much for your appreciations and encouragements.

Results: Reviewer #2 Comments to the authors

• I recommend that the authors maintain a consistent number of decimal places in the tables presented.

• The authors must review the tabular data presented as some of the frequencies and percentages do not add up or tally. Eg Table 2 “No of ANC follow up” and Table 3 “When starts breast feed”

• The results section has very little qualitative data representation. I recommend that the results section would be made more interesting with the inclusion of additional quotes from qualitative responses. I recommend that quotes regarding reasons for time of giving colostrum and how HIV status disclosure affected breastfeeding would be interesting and give support to the quantitative results. This would also strengthen the claim of triangulation cited in the strengths section of the manuscript.

Results: Authors Response to Reviewer #2

• Thank you for the comments, this is relevant for enrichment of data presentations. We have maintained uniform/consistent decimal point (one decimal points) presentations throughout the revised main text manuscript.

• Tabular data presentations. We have carefully cross-checked the discrepancy and addressed them accordingly in the revised manuscript. We have highlighted the changes in the corresponding tables. I.e. Table 2 “No of ANC follow up” and Table 3 “When starts breast feed”

• Though the qualitative data is very important for the enrichment of this manuscript, for this manuscript, we have removed qualitative data because of we felt that we could not address it very well here. We may come back with separate manuscript exclusively with qualitative data.

Attachment

Submitted filename: Response to Reviewers.docx

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Decision Letter 1

Kwasi Torpey

20 Jan 2022

PONE-D-21-08205R1Factors influencing Exclusive Breast Feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.PLOS ONE

Dear Mr Elias Roro,

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Academic Editor

PLOS ONE

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Reviewer #2: (No Response)

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Reviewer #2: Partly

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Dear Editor

Review of Manuscript PONE-D-21-08205

Comments to the authors

I appreciate the work put in by the authors to address my earlier comments and incorporate recommendations.

Again I would like to stress the importance of having this manuscript professionally copyedited and proofread due to existing grammatical errors in the script.

The following are detailed comments and recommendations

Results

The authors must again review the tabular data presented as some of the frequencies and percentages are wrong.

The authors would either have to include the qualitative quotes in the results section or drop their claim of using triangulation.

I hope that the authors will consider these suggestions in improving the manuscript to address this very important topic. I wish them all the best in this endeavour.

**********

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Reviewer #2: No

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PLoS One. 2022 Aug 8;17(8):e0271167. doi: 10.1371/journal.pone.0271167.r004

Author response to Decision Letter 1

3 Apr 2022

Response to Reviewers

Title: Factors influencing Exclusive Breast Feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.

Authors: Ejigayehu Tolessa Bultum (ebultum@yahoo.com

Elias Merdassa Roro (emerdassa@gmail.com)

Tsedeke Wolde (tsedekewolde@yahoo.com)

Ilili Feyissa Regassa (liasfeyisa2@gmail.com)

Version: 3 Date: 03 April 2022

Author’s Response to Reviewers Comments: See over

Editor’s Comments

Version: 3

Date: 03 April 2022

Title: Factors influencing xxclusive breast feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.

Editor’s comment -1

1. Again, I would like to stress the importance of having this manuscript professionally copyedited and proofread due to existing grammatical errors in the script.

Authors Response -1

1. Thank you for the comment. The revised manuscript has been copy edited for language usage, spelling and grammar by health professional from Australia by a native English speaker. The editor had a rich experience in editing manuscripts. The editor is currently post-doctoral fellow at the university of Queensland Mater research institute.

Results

Editor’s comment -1

1. The authors must again review the tabular data presented as some of the frequencies and percentages are wrong.

2. The authors would either have to include the qualitative quotes in the results section or drop their claim of using triangulation.

Authors Response -1

1. This is very relevant comment. In the revised manuscript we have revised our tables across the document. We have now revised some of the frequencies and percentages in table 2,3 & 4 in the revised manuscript. We indicated those changes using track and changes. We have now the manuscript with those changes labelled and uploaded as ‘manuscript with track change’ document.

2. We have already removed the qualitative section and dropped the triangulation claim from the manuscript.

3. We have also modified the Abstract section. This modification is also indicated in modified manuscript labeled as “manuscript with track changes”

It reads as follows:

‘In our study, only just over half of the mothers practiced EBF for the first six months. Care providers should continue to encourage mothers to practice EBF in the first six months and to disclosure of HIV status to someone close to them including their husband. Efforts should be in place to curb the risk of HIV/AIDS transmission during delivery. Continues advise for mothers to practice EBF in the first 6 months is still needed.’

Attachment

Submitted filename: Response to Reviewers-II.docx

Click here for additional data file. (20KB, docx)

Decision Letter 2

Kwasi Torpey

27 Jun 2022

Factors influencing exclusive breast feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.

PONE-D-21-08205R2

Dear Mr Elias Roro,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Professor Kwasi Torpey, MD PhD MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Copyediting done but a few typos remain which can be addressed during production

Reviewers' comments:

Acceptance letter

Kwasi Torpey

14 Jul 2022

PONE-D-21-08205R2

Factors influencing exclusive breast feeding among children born to HIV positive mothers attending public health facilities in western Ethiopia: Cross-sectional study.

Dear Dr. Roro:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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on behalf of

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